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The Robert Koch Institute is the German government's central institution for the identification, surveillance and prevention of infectious diseases in the Portfolio of the German Ministry of Health.
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Preface

The figures for vaccinations are growing – but does this make us healthier? This question has been discussed time and again, and not just in the last few years. When mandatory smallpox vaccinations were introduced for children by the “Reichsimpfgesetz” (Vaccination Act) of 1874, the debate was fierce, and critics started up journals such as “Der Impfgegner” (the vaccination objector) to create a platform for their arguments. Today, too, the debate often revolves around vaccinating children. People ask whether the jabs do children more harm than good. Are vaccinations dangerous or superfluous? What part does the pharmaceutical industry with its profit motive play?

One thing is clear: vaccinations are different from other medical interventions. For one thing, they do not only seek to benefit the individual but to protect the wider population. For another, they are given to healthy subjects. It is quite justified to demand special care when it comes to vaccinations and to discuss controversial issues critically – not least because vaccinations are one of the most common medical procedures of all. In Germany in 2011, for example, about 35 million doses of vaccine were reimbursed by the statutory health insurance providers. Around 40 per cent of these were the annual flu jab, whilst child vaccinations accounted for another major proportion.

In 2012, more than 95 per cent of children starting school had been vaccinated against diphtheria, tetanus, whooping cough, polio and had received at least one measles, mumps and rubella vaccination. Approximately 85 per cent had also been vaccinated against hepatitis B, which has been recommended for infants since the mid-nineties.

Germany does not have mandatory vaccinations. Everyone can refuse vaccinations, both for themselves and their children, without stating their reasons. And many of those who describe themselves as vaccination objectors or vaccination critics do precisely this.

The most frequent objections to vaccinations are listed here. The answers provide information around the issues raised in order to allow an informed and balanced view of the benefits of vaccination. The document was jointly prepared by the Robert Koch-Institute and the Paul-Ehrlich-Institut, the Federal Institute for Vaccines and Biomedicines, in 2007. This is an updated version.

1: The effectiveness of vaccinations has never been proven.

According to current pharmaceutical legislation, a vaccine is only licensed when it has been proven that it is effective and well-tolerated. The manufacturer must provide this proof by conducting pre-clinical tests and clinical trials. The results are checked at EU level by the European Medicines Agency (EMA). Within Germany, the Paul-Ehrlich-Institut carries responsibility in its role as Federal Institute for Vaccines and Biomedicines.

Moreover, once a vaccine has been licensed, further ongoing studies are conducted to monitor its effectiveness and safety. These studies are often undertaken by the manufacturers but also by independent scientists at universities and research institutes. Consequently, the effectiveness and safety of vaccines that have been in use for decades, such as measles vaccines, have been demonstrated on millions of people. The fact that it has been possible to successfully reduce the occurrence of measles worldwide and avoid deaths is just one of the ways in which this effectiveness expresses itself.

Another well-known example is the introduction of oral polio vaccination at the beginning of the 1960s. Whilst in Germany in 1961, nearly 4,700 children suffered from polio, by 1965, the figure was down to fewer than 50. Since 1990, there have been no further cases of the disease caused by wild polio viruses (see also answer to Objection 17).

A similar impact was achieved by vaccinating against Haemophilus influenzae (Type B) bacterium which can cause meningitis in babies and toddlers. In the former German Democratic Republic (GDR), where all infection figures were registered very precisely, roughly 100 to 120 cases of meningitis occurred every year prior to 1990. After the introduction of Haemophilus vaccination throughout Germany in 1990, the annual number of cases in the eastern German federal states rapidly fell to fewer than ten annually.

2: None of the supposedly disease-causing pathogens has yet been seen, isolated or their existence definitively proven.

No pathogen, no vaccination – this is one of the unwritten laws of microbiology. Vaccinations are extracted from weakened or inactive pathogens or their components. In some cases, closely related strains are used to produce vaccines. So without specific information about the pathogen it would not have been possible to systematically develop a vaccine. By using this knowledge to develop a vaccine, it becomes possible to prepare the body’s immune system so that it is ready, should it ever encounter the actual pathogen.

The fundamental methods in bacteriology were pioneered by Robert Koch. These included the development of solid culture media for bacteria and the introduction of microphotography. These techniques contributed significantly to growth in the scientific field of bacteriological research. In 1876, whilst working as a district physician, he discovered that anthrax spores were the dormant form of anthrax pathogens and thus explained how the infection was transmitted and why the bacterium had such a high resistance to environmental factors, which had not previously been understood. In doing so, Robert Koch became the first person to prove the connection between a microorganism and the cause of a disease. Taking images of viruses on the other hand was not possible for a very long time because they are too small to be captured by an optical microscope. It wasn’t until the introduction of electron microscopy in the 20th century, that detailed images of the viruses became possible.

Moreover, in many cases it is now possible to identify the genetic code of pathogens. One of the ways in which this knowledge has been used is to genetically engineer the hepatitis B vaccine in yeast cells. The vaccine’s effect is mediated purely by a specific surface molecule of the hepatitis virus, known as the HBs antigen. The production of many flu vaccines, by contrast, is much more traditional: the flu viruses are proliferated in chickens’ eggs. The viruses are subsequently killed and processed into highly-purified vaccines.

3: Vaccinations are not effective long term and have to be repeated constantly.

Whether vaccination has to be repeated or not depends on the vaccine. If, for example, a child has received two doses of the combined measles, mumps, rubella vaccine in the context of basic immunisation, it can be assumed that immunity to measles and rubella will last a lifetime.

This is not true of tetanus, diphtheria, polio and whooping cough. Vaccinations against these diseases last for five to ten years – then they have to be repeated. Flu vaccinations are effective for a much shorter period of time: people in at-risk groups need a booster every year. This is because the influenza pathogen changes incredibly quickly and the influenza vaccine needs to be adapted to remain effective.

The need for repeated vaccination does not mean that it is less effective. In chronically ill or older people, an annual flu vaccination can reduce the risk of the disease becoming life threatening. And an injection every ten years seems a small price to pay for immunisation against tetanus, which can be fatal.

Furthermore, it should be remembered that even people who have survived a certain infectious disease are not immune to this disease for ever. You can contract tetanus, diphtheria and whooping cough more than once. There have even been several cases documented of people who have caught measles twice.

4: You can still catch an infection even if you have been vaccinated against it.

There is no vaccination that is guaranteed to work without exception for every single individual, just as there is no drug that is effective on all patients. However, vaccinations can significantly reduce the probability of contracting a specific infection.

Imagine the following scenario: a measles epidemic breaks out in a primary school. Half of the children have been vaccinated, the other half have not. Statistically, approximately 97 to 98 per cent of the unvaccinated children will catch the disease compared to two to three per cent of those vaccinated. The flu vaccine, however, is not as effective. Depending on age and health status, it protects roughly 40 to 75 per cent of those vaccinated, working least well in older people.

Furthermore, vaccinations may be less effective if boosters are not given on time or immunity has not yet been completely achieved. The routine childhood vaccinations, for example, initially have to be repeated according to a fixed timetable in order to achieve reliable, sustained protection.

In addition to this, there are some vaccinations which primarily prevent particularly serious manifestations of a disease. This is true of the BCG vaccine against tuberculosis that was part of standard immunisation routine for babies in Germany up until the late nineties. The vaccine did not protect children from becoming infected with tuberculosis but it did protect them from the most serious forms of the disease affecting the brain or the whole body. It has now been taken out of the routine vaccination programme because of the comparatively low likelihood of catching the disease.

5: Experiencing infections is important for a child’s normal development and induces better immunity than vaccinations.

Sometimes parents report that their children make developmental leaps when they have got over an infectious disease. They infer that infectious diseases are important for children’s normal development and that vaccinations delay it. There isn’t a plausible biological explanation for this and to date, scientific studies have never demonstrated that unvaccinated children develop either mentally or physically better than vaccinated children. Existing vaccines only target approximately a dozen particularly frequent or dangerous pathogens - the immune system has to deal with hundreds of other pathogens on a daily basis.

The vaccination itself stimulates the immune system. Consequently, it would be extremely surprising if vaccinated children were generally constitutionally weaker or had poorer immune defences long-term. Even where a positive change may be attributed to an illness as described above, it is undisputed that infections usually hinder children’s development and can lead to health complications and even death. With the help of vaccinations these consequences can be avoided.

6: We parents had these infectious diseases when we were children and we got over them all right.

It is true that many infections can be overcome without consequences. Even so-called childhood diseases, however, can sometimes take a dramatic course. At the end of the 1940s, before vaccines were available, several thousand people died of typical childhood diseases like diphtheria, whooping cough and polio every year in Germany. In 1949, in the Federal Republic of Germany alone, 1,100 deaths were recorded as a result of diphtheria.

The term childhood disease does not mean that an illness is harmless but that for many years, it tended to occur during childhood. The best example is measles: roughly one child in a thousand that catches measles develops a specific inflammation of the brain, known as measles encephalitis. This often causes permanent brain damage and can be fatal. The measles virus has also been proven to weaken the sufferer’s immune system, increasing the risk of bacterial cross-infections such as pneumonia and middle-ear infection.

Much the same is true of childhood diseases such as mumps and rubella. Mumps in young men can cause inflammation of the testicles and potential fertility problems. Vaccination can usually prevent this complication. In the case of pregnant women who are not immune to rubella, the disease can result in serious deformities in the unborn child. Two doses of rubella vaccine almost completely protect against this possible consequence of the disease.

Years ago, it was impossible to protect oneself against a whole host of diseases by vaccination, just as there were no seat belts in cars and no helmets for motorcyclists and cyclists. Today, we do have all these means of protection – and we use them.

7: Babies get antibodies from their mothers. This natural protection is sufficient.

It is certainly true that pregnant women transfer antibodies that protect against certain infections via the blood circulation to their unborn child. The new-born baby may also receive additional antibodies through the breast milk. However, this maternal passive immunity only supports the child’s immunity during the first months of life while it is developing its own immune system – and it only extends to certain infectious diseases.

A mother can only transfer antibodies against diseases she herself has had or has been immunised against, and only when the concentration of antibodies against the respective pathogen in her own body is high enough.

For example, whooping cough: because the antibodies that develop after a whooping cough infection or vaccination start decreasing after just a few years, most mothers can’t transfer enough (or any) whooping cough antibodies to their babies. If a mother is vaccinated during pregnancy, however, and develops antibodies, this can generate sufficient maternal passive immunity to protect the infant from whooping cough for a period of time after birth. This does not replace vaccinating the infant which can be done from the age of two months.

Measles is a different matter: the child of a mother who is immune to measles is only protected against measles for at most six months after birth. Duration of protection in children whose mothers have been vaccinated is in general shorter than that of those whose mothers have had a measles infection themselves. Breastfeeding does not induce immunity to measles in infancy. Young women should, therefore, be sure that they are immune to measles before becoming pregnant so that they can transfer antibodies to their unborn child. It is not possible to vaccinate during pregnancy. Furthermore immunity in the family builds a firewall against measles which can protect the infant after maternal passive immunity comes to an end and until the child can be vaccinated.

As maternal antibodies are only gradually transferred to the unborn baby via the placenta, passive immunity is often reduced in premature babies. Particularly these children benefit from vaccinations being administered to both them (unless contra-indicated) and their families.

Quite apart from this, maternal passive immunity and vaccinations are not mutually exclusive; they can complement each other. Swedish paediatricians have shown that children who have been breastfed are less likely to suffer from serious meningitis caused by the Haemophilus influenzae (Type B) (Hib) bacterium and also develop more antibodies against the pathogen after a Hib vaccination. Only when a complete course of vaccines has been administered is it usually possible to avoid meningitis altogether.

8: Women who have had an infection pass on more antibodies to their children than women who have been immunised for the same condition.

This has been proven with regard to measles, mumps and rubella. Vaccination against these diseases stimulates the mother’s immune system less than a wild virus infection. Thus, by comparison, the antibody level of infants of vaccinated mothers is lower than that of infants of mothers who have had measles, and it also drops faster. This does not, however, mean that it would be better to forgo the vaccination altogether. All three diseases can take a dramatic turn both in children and adults and cause major complications. The vaccine protects against these diseases and has saved millions of lives since it was introduced worldwide.

It is also important to note that a mother does not transfer antibodies against all infectious diseases to her baby. An example of this is whooping cough infection in the mother, where the antibodies produced fall rapidly after the infection is over, meaning that a new-born baby is rarely covered by maternal passive immunity. It is now known that adults can catch whooping cough several times in their lives and infect their children without realising. A study in the United States in 2007 revealed that parents and close relatives are by far the most frequent source of infection in infants with whooping cough. The German Standing Committee on Vaccination therefore recommends that all those in immediate contact with babies should be vaccinated before the infants are born.

For other infections such as tetanus and diphtheria, infants whose mothers have been immunised are protected through maternal passive immunity. However, such protection has not been proven with regard to infants whose mothers have had the infection.

9: Early vaccinations pose avoidable risks to children.

Some infections affect infants much more than older children – and this is one of the main reasons why babies are vaccinated against a range of diseases at just eight weeks after birth.

Classic examples include Haemophilus influenzae infections and whooping cough. If children contract whooping cough under the age of six months, in approximately 25 per cent of cases they develop complications like pneumonia and respiratory arrest. Above this age, this figure drops to roughly five per cent. So infants, in particular, benefit from whooping cough vaccinations. Even after the first dose at eight weeks, the probability that the child will have to be hospitalised due to whooping cough drops by about two-thirds. The subsequent doses during the first year of life complete the whooping cough immunisation schedule.

The assumption that infants in general are less tolerant of vaccinations than older children has not been proven. Very premature babies, born before the 32nd week of pregnancy, should be given special checks of their hearts and lungs after certain vaccinations to ensure that any complications associated with the vaccination are recognised promptly, but premature babies are also more susceptible to infections. Here again, the risk-benefit ratio is in favour of vaccination.

Not all vaccines are administered to infants however. Children are not immunised against measles, mumps and rubella as well as certain meningitis pathogens, known as meningococci, until after their first birthday.

The fact is that, today, children are vaccinated against more infections than they used to be. But the number of antibodies transferred in each vaccine has dropped significantly. The old whooping cough vaccine, for example, included the entire bacterium with 3,000 different antibodies. By contrast, all the vaccinations used today only contain 150 different antibodies in total. The reason for this is that modern vaccines are highly purified and usually only contain a single constituent of the pathogen. In reality, a child’s immune system, which is highly fit for purpose, deals with a far larger number of antibodies every day than occur in vaccines.

Moreover, there is no evidence to suggest that multivalent vaccines overburden the immune system. However, it is true that certain sub-constituents of combined vaccines stimulate the immune system less than when they are administered separately. This is why a vaccine may need to be administered over four doses (or part doses) instead of three. In the end though, the number of jabs required overall can be reduced significantly by using multivalent vaccines.

Nowadays, up to six vaccines – against tetanus, diphtheria, whooping cough, Haemophilus influenzae, polio und hepatitis B – can be combined into one single vaccine. One of the criticisms frequently levelled against the hexavalent vaccination is that hepatitis B is essentially – though by no means exclusively – transmitted by sexual intercourse and thus the likelihood that an infant will contract the disease is very low. Nonetheless, in infants who do contract hepatitis B, it is almost always extremely serious and in 90 per cent of cases becomes chronic.

In addition to this, there are practical considerations involved in vaccinating infants against hepatitis. We know that vaccination rates amongst young people are low whilst an infection with hepatitis B can lead to very serious illness and even cause cancer of the liver if it becomes chronic. Both the German Standing Committee on Vaccination and the World Health Organisation (WHO) therefore recommend vaccinating children against hepatitis B. On the basis of current knowledge, in a large proportion of those vaccinated this can mean long-term or even life-long protection.

11: Vaccinations cause the diseases they are supposed to prevent.

Very few vaccines contain attenuated pathogens that are still alive. This can indeed induce symptoms similar to the disease itself, but these symptoms almost never develop into a full-blown disease. “Vaccine-induced measles” is a well-known example. Because the measles vaccine contains a weakened measles virus which is still able to reproduce, in about five per cent of those inoculated it causes a measles-like rash and fever about a week later. These symptoms usually indicate that a high level of immunity is developing. Full-scale measles and its serious complications such as middle-ear infections or pneumonia do not occur. Even the much-feared swelling of the brain, measles encephalitis, only occurs in exceptional cases after measles immunisation. Individual occurrences have been reported, in particular in people with contraindications to the measles vaccination (e.g. diseases of the immune system). It is almost never seen in healthy people.

Unfortunately, during the period when oral vaccinations were administered for polio, there were cases of polio being caused by the vaccination itself. The live vaccine, which was highly successful in helping to suppress polio, did cause a few infections every year. For this reason, live vaccinations are no longer used. Since January 1998, the German Standing Committee on Vaccination has consequently recommended the use of inactivated vaccines administered by injection which cannot trigger the disease.

Most vaccines contain inactivated pathogens or, as in the case of flu vaccines, just selected parts of the pathogen. Such vaccines are unable to cause disease. Irrespective of the type of vaccine, fever, nausea or drowsiness may occur after vaccination, and the injection site may swell up or become red. This is partly due to an appropriate reaction by the immune system to the vaccine and usually indicates that future immunity to the disease will be good.

12: Vaccinations promote allergies.

One thing is certain: today there are more vaccinations – and more allergies. Whether there is a link between the two, however, has not been proven. Admittedly, a few years ago, Swedish doctors demonstrated that children from anthroposophical families (who are vaccinated less often) were less likely to suffer from eczema. However, they were also given fewer antibiotics, had a different diet and their parents smoked less. In another study, American allergists discovered that parents who reject vaccinations observe fewer cases of asthma and hay fever amongst their children. But this study, too, failed to determine whether there was really a causal link between not vaccinating and the occurrence of asthma or hay fever.

Many other studies speak against a connection of this kind. An analysis by doctors in Rotterdam, for example, who reviewed the scientific literature published on the subject between 1966 and 2003, concluded that especially the methodologically sound studies did not show an increased risk of allergies. On the contrary, it emerged that vaccinations could reduce the risk of allergies developing.

Experience in this country points in the same direction: in the German Democratic Republic (GDR), where vaccinations were mandatory and nearly all children were vaccinated, allergies were not an issue. They only started to increase in East Germany after reunification whilst the vaccination rates dropped.

13: The risks and side-effects of vaccinations are incalculable.

There has been an ongoing debate in recent years whether autism, diabetes and even multiple sclerosis could be triggered by vaccinations. To date, there is no evidence for this and there are numerous studies that suggest that there is no link between vaccinations and these diseases.

At the end of the 1990s, a British doctor, Andrew Wakefield, conducted a very small-scale study (twelve children) and came up with the hypothesis that the measles-mumps-rubella vaccination could damage the intestines and allow uptake of neurotoxic substances. He claimed this affected intellectual development and could potentially lead to autism. Major studies were carried out to verify this hypothesis but none of them confirmed this association. It then emerged that Wakefield had received payment from lawyers representing the parents of autistic children who were searching for a link between autism and vaccinations in order to sue the manufacturers. In 2004, ten of the 13 authors of the original study officially retracted their interpretation. In 2010, the doctor responsible was accused of unethical behaviour and lost his licence to practice medicine.

This notwithstanding, it is undisputed that vaccines can have side effects. One of the main difficulties is to determine the level of risk associated with a vaccine as nearly all children are vaccinated. It therefore comes as no surprise that health issues and diseases that occur frequently in childhood happen to be noticed around the same time as vaccinations. But this does not necessarily mean that there is a causal connection with the vaccination. Some years ago, for example, it was suggested that vaccinations could be responsible for facilitating cot death because a number of babies died shortly after having been vaccinated. Since then, studies have indicated that the opposite is actually true. Medical researchers at the University of Magdeburg, for instance, conducted an extensive study of more than 300 cot deaths and ascertained that fewer of these babies had been vaccinated, or only at a later stage, than is usually the case.

The German Protection against Infection Act and other regulations stipulate that suspected cases of vaccination complications must be reported to the Paul-Ehrlich-Institut. The institute investigates whether there is a causal connection between these reports and the vaccination in order to determine potential risks of very rare side effects at an early stage and be able to take the necessary measures. This ensures that the vaccines are subject to continuous safety monitoring even after they have been licensed.

Some vaccines contain formaldehyde, aluminium, or phenol – but only in extremely low concentrations (well below the known toxicological limits). These substances serve specific purposes such as killing the vaccine virus (formaldehyde), boosting the immune response (aluminium hydroxide) and conserving the vaccine (phenol).

Some years ago, two American physicians launched the theory that the increase in cases of autism registered in the United States was linked to the preservative “thimerosal” which contains ethylmercury, an organic mercury compound, and has been used in inactivated vaccines. In the interim, however, both the World Health Organisation (WHO) and the American “Institute of Medicine” as well as the European Medicines Agency (EMA) have independently reached the conclusion that existing studies speak against a connection of this kind. Nonetheless, the pharmaceutical industry responded to the heated debate accordingly: nowadays, no vaccine contains “thimerosal”, except pandemic influenza vaccines which are not formulated in single syringes.

15: During the manufacturing process, vaccines can become contaminated with substances that cause diseases like BSE, AIDS and cancer.

It is true that serum taken from calves, for example, is used as a growth medium in the cell cultures for cultivating certain vaccine viruses. But the only products that are allowed are those from countries that are certified BSE-free, like New Zealand.

Controls are similarly strict with regard to certain protein constituents like the so-called human albumin that is extracted from human blood plasma. These proteins are sometimes used to help to stabilise and conserve live vaccines. In order to prevent the transmission of viruses like HIV or hepatitis, plasma products are systematically tested for pathogens. Moreover, in the further course of manufacture, additional procedures ensure that the products are generally germ-free. It is impossible for cancer to be caused by using cells taken from tumour tissue to produce vaccines containing influenza viruses. These cells are used because they can multiply without limit, but the cell constituents themselves are not contained within the vaccine.

Serious production errors, which – just as in any manufacturing process – can lead to disaster, have not occurred in the immediate past. In the 1950s, shortly after the routine introduction of the inactive polio vaccine in the United States, the vaccine was accidentally contaminated by active polio viruses. Several hundred thousand children were infected, 50 suffered permanent paralysis and five died. This serious event is known as the “Cutter Incident” after the manufacturer, Cutter Laboratories.

The control mechanisms used in drug safety are updated regularly using recent scientific advances. Thanks to a novel testing method, a vaccine against the rota virus was discovered to be contaminated with the Porcine Circovirus 1, or PCV1, in 2011. With the help of other specific detection methods, scientists at the Paul-Ehrlich-Institut and the Robert Koch Institute, amongst others, determined that the vaccine did indeed contain large amounts of PCV1 particles but that they were not infectious and hence not a health risk.

16: There are doctors who advise against vaccinations.

Only very few doctors are wholeheartedly against vaccinations. There are, however, some who have a critical attitude to certain individual vaccinations. This does not mean that there are good scientific reasons for their stance. Personal experience, religious or philosophical convictions play a big role in such attitudes.

A preference for alternative medicine does not necessarily collide with the idea of vaccination. Some years ago, researchers in Freiburg conducted a survey of more than 200 homeopathic doctors and ascertained that they administered “classic” vaccinations against tetanus, diphtheria and polio almost as often as their colleagues in conventional medicine. A change in thinking is occurring with regard to measles vaccinations, too. Many naturopathic and homeopathic doctors now explicitly recommend this vaccination. In a statement published in 2002, the German Homeopathic Association (DZVhÄ) emphasised that the debate about the advantages and disadvantages of vaccinations was completely legitimate and that every individual had to decide for themselves. At the same time, the DZVhÄ endorsed the importance of the German Standing Committee on Vaccination. It claimed the latter’s recommendations were ‘carefully considered and take account of the state of knowledge with the fundamental aim of preventing the occurrence of infectious diseases.’

17: Most of the diseases vaccinated against do not occur in Germany anymore.

Some infections like polio have not occurred in Germany for many years or, like diphtheria, have become a rarity. This in itself is, however, the result of vaccination programmes. When vaccination levels drop, the risk of new epidemics re-emerges. This is illustrated by polio outbreaks in some religious communities in the Netherlands, which reject vaccination on principle, in 1978 and 1992. 110 people contracted polio during the first epidemic, 71 during the second. Even after the World Health Organisation (WHO) had declared the WHO region Europe to be polio-free in 2002, wild polio viruses were reintroduced to the region. In Tajikistan, more than 600 cases of acute flaccid paralysis were reported in 2010. In 334 of them, a wild polio virus was detected. Of the confirmed cases, 14 ended in death. The virus, which had originated in India, spread from Tajikistan to Russia despite safety precautions (travel ban, import ban on foodstuff) and caused several further cases there, too.

Far more dramatic even than these polio outbreaks were the diphtheria outbreaks which hit Russia and other countries of the former Soviet Union in the 1990s. Due to falling vaccination rates, over 150,000 people caught diphtheria and more than 6,000 died. In the wake of such epidemics, international travel could also lead to the introduction of infections into Germany.

18: Vaccinations aren’t needed because illnesses can be treated with antibiotics or other medications.

Undoubtedly, treatment options today are better than they used to be. Right up to the present, however, there are no medicines that can deal with viruses as effectively as antibiotics can treat bacteria. Faced with viruses, antibiotics are ineffective.

But antimicrobial resistance is increasingly limiting the options for treating bacterial diseases. In addition, in the last few decades, very few new antibiotics have reached the market. So in 2014, the World Health Organisation warned that unless many of those involved urgently coordinated activities, the world would face a post-antibiotic era. One aspect of this is that there is less need for antibiotics if bacterial infections are prevented by vaccinations and improved hygiene.

Some bacterial diseases are very difficult to treat. Tetanus infections, bacterial meningitis and whooping cough, for instance, can prove fatal even under modern treatment regimes.

On top of this, vaccinations and therapy are not contradictory alternatives but part of the same safety chain. Whilst the vaccination may not prevent an infection in all cases, it can still reduce the severity of the illness.

19: The decline in diseases is a consequence of improved hygiene and nutrition. It has nothing to do with vaccinations.

One thing is clear: prosperity and hygiene play a major role in preventing infectious diseases. A supply of clean drinking water and regular hand hygiene, for example, are essential for preventing hepatitis A, typhoid and cholera. Many infections were already on the decline prior to the introduction of vaccinations as a result of improved hygiene and better nutrition. It is not to be expected, however, that improved hygienic conditions will lead to such a clear drop in the occurrence of infections as vaccinations. Some pathogens like measles, hepatitis B and polio viruses are hosted exclusively in the human body and passed from person to person by sexual contact or coughing.

Whilst it is true that measles, for example, often take a more serious course in undernourished children, nearly everyone who has not been vaccinated and catches the virus does develop the disease. The larger the number of people in the environment who are vaccinated against measles, the less the chance of encountering the virus becomes – because chains of infection are broken (herd immunity). If more than 95 per cent of the population are immunised against measles, measles can be completely eradicated.

North and South America are an example. As a result of a rigorous vaccination programme, the continent is effectively measles-free and, since 2015, also rubella-free. In some African countries, particularly in Sub-Saharan Africa as well as in India and Southeast Asia on the other hand, measles is still one of the frequent causes of death. In 2014, some 115,000 children still died of measles in these countries. The WHO estimates, however, that since vaccinations were introduced in 2000, some 17 million deaths have been prevented. In the long term, the WHO aims to eliminate measles worldwide. Germany is working towards this goal.

20: The pharmaceutical industry just wants to make money with vaccinations.

Private companies in all sectors have a legitimate interest in making a profit with their products and the pharmaceutical industry is no exception. However, one should be aware that there is a huge financial difference between the business of medicines and that of vaccines. Of the nearly 194 billion euro spent by statutory health insurance providers in 2014, 33 billion (17%) went on medicines and only just over one billion (0.65%) on vaccines. One of the reasons for this is that many medicines have to be taken e.g. by chronically-ill patients during their entire lifetime whilst vaccines are usually only administered a few times.

From the point of view of the pharmaceutical industry, the vaccine business is therefore less attractive because it is far more complex and expensive to produce vaccines than medicines. There are ever fewer vaccine manufacturers across the world, which may be a consequence of economic considerations. On the other hand, it is also important to remember that vaccinations obviate the necessity for expensive therapies and also avoid much suffering on the part of patients. This has been calculated in many evaluations of health care costs.